Richard M. Fairbanks School of Public Health Theses and Dissertations

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Obesity Severity Phenotypes, Relevant Biomarkers, and Cardiovascular Disease: The Cross-Cohort Collaboration (CCC)
(2025-05) Dardari, Zeina; Zhang, Jianjun; Bakoyannis, Giorgos; Nan, Hongmei; Staten, Lisa; Blaha, Michael
The global obesity pandemic is well documented and continues to pose a major public health threat. In 2022, the World Health Organization (WHO) classified more than 2.5 billion adults worldwide as overweight, including 890 million with obesity. In the U.S., projections indicate that by 2030, 1 in 2 adults will have obesity (BMI ≥30 kg/m²), and 1 in 4 will have severe obesity (BMI ≥35 kg/m²). Obesity is a well-established risk factor for numerous diseases, including type 2 diabetes mellitus, hypertension, obstructive sleep apnea, fatty liver disease, osteoarthritis, cancer, and cardiovascular disease (CVD), such as coronary heart disease (CHD), stroke, heart failure (HF), and atrial fibrillation (AF). Using the Cross Cohort Collaboration (CCC), a harmonized dataset of 24 U.S.-based prospective cohort studies, we examined the relationship between BMI and CVD outcomes across a broad BMI spectrum, with a focus on severe obesity (Class II: BMI 35.0–39.9 kg/m²; Class III: BMI ≥40.0 kg/m²). Our findings show that while obesity was associated with increased risk for all outcomes, stratifying obesity into sub-classes revealed that relative risk increases with obesity severity, even after accounting for traditional CVD risk factors. We also evaluated the long-term impact of central adiposity on multiple CVD subtypes, with particular attention to discordant adiposity groups (e.g., normal BMI with elevated central adiposity). Our findings underscore the need to identify and address central obesity, even among individuals with a normal BMI. These results support incorporating central adiposity measures as routine clinical assessments to improve cardiovascular risk stratification. Finally, we explored the relationship between obesity and subclinical markers of inflammation, thrombosis, and atherosclerosis to better understand underlying mechanisms. Our results demonstrated a positive, graded association between BMI and elevated levels of these markers, with the strongest associations observed in Class III obesity.
Aligning Priorities Between Community Need for Lung Cancer Screening Programs and Hospital Effectiveness - A Policy Analysis
(2025-05) Tackett, Scott Michael; Marstein, Egil; Babich, Suzanne; Culbertson, Richard
Objective: Investigate structural factors impacting the prioritization and funding of public health preventive lung cancer screening programs in U.S. hospitals. Additionally, provide change leadership recommendations on policies to improve the implementation of evidence-based practices. Data sources and study setting: Data was gathered through a systematic literature review and primary qualitative research from health system or hospital organizational leadership across the U.S. Study design: The research employed a descriptive, non-experimental, convergent mixed-methods approach. Quantitative and qualitative data were collected and analyzed independently, then combined to obtain detailed insights from various perspectives across a diverse system for a situational analysis. Data Collection and Methods: A systematic literature review, combined with semi-structured interviews with Chief Medical Officers, Chief Financial Officers, and lung cancer program executives, was conducted across U.S. hospitals and health systems. Purposive sampling included thirteen dyad executive pairs and two executives from integrated delivery network lung cancer programs, representing various regions with a 'representative voice' of 6% of U.S. hospitals. Principal findings: The data synthesis identified 18 factors affecting lung cancer screening programs, categorized into five themes: differing missions, governance models, misaligned economics, competing goals, and broad agreements. These themes illustrate national discussions influencing the implementation of these types of preventive public health programs in hospitals and integrated delivery network organizations. Discussion: Despite efforts to implement evidence-based practices, outcomes and annual adherence rates remain low, showing room for improvement. This study is the first to provide empirical evidence that system-level factors in healthcare governance, processes, economics, and strategic decisions significantly influence the prioritization and investment in lung cancer screening programs and initiatives to implement an evidence-based practice. Summary & Conclusions: CMS should implement policies linking quality measurement with economic incentives in lung cancer care. These policies aim to prioritize investments supporting implementation practices. Their adoption requires political and agency leadership and represents a significant shift in approach. Aligning with these types of motivating economic incentive policies could impact the entire U.S. healthcare system.
Establishing Policy Governance for Department of Defense Global Health Engagement Supporting United States Government Security, Defense, and Global Health Security Priorities: A Policy Analysis
(2025-02) Cincotta, Jacqueline Viola-Ann; Babich, Suzanne; Marstein, Egil; Petzing, Stephanie
Introduction. The United States (U.S.) Department of Defense (DoD) conducts DoD Global Health Engagement activities to support U.S. national, defense, and global health security priorities. The guiding policy for DoD Global Health Engagement is DoDI 2000.30 “Global Health Engagement Activities.” Problem Statement. The current DoDI 2000.30 “Global Health Engagement Activities” lacks an established governance framework and structure to oversee and ensure DoD Global Health Engagement activities enable U.S. national, defense, and global health security priorities. Methods. A complete policy analysis was conducted to devise policy alternatives for establishing DoD Global Health Engagement governance in DoD Global Health Engagement policy. Results. The policy analysis identified direct and indirect linkages DoD supports U.S. national, defense, and global health security priorities, as well as associated gaps in current DoD Global Health Engagement policy. Policy Alternatives & Plan-of-Action: A proposed DoD Global Health Engagement Governance Framework is introduced to recommend incorporating into DoD Global Health Engagement policy, as well as a plan-of-action utilizing social marketing to facilitate uptake of the proposed governance framework.
Leadership Changes to Support Healthcare Providers with Long COVID Care
(2025-04) Weideman, Angela Katherine; Czabanowska, Katarzyna; Bigatti, Silvia; Modji, Komi
Objective: To explore how public health leaders and long COVID stakeholders from the Midwest United States can best support healthcare providers in providing long COVID care and how they can help ease the burdens of such care. Data sources and study setting: Qualitative interviews with 34 long COVID stakeholders from the Midwest region of the United States, from 15 different stakeholder groups, were collected from December 2024 to February 2025. Study Design: The research design was a qualitative study in which key informant interviews were conducted with stakeholders of long COVID using a semi-structured interview. Data collection: Semi-structured, one-on-one interviews were conducted virtually using Microsoft teams, and interviews were audio recorded and transcribed using Microsoft teams. Interviews were then coded using NVivo for inductive coding, used to identify and describe themes. Principal findings: The challenges identified related to diagnosis, access to care, provider concern, communication, and treatment. Stakeholders identified that they have impact and influence related to helping patients get to diagnosis and treatment more quickly, setting or supporting policies, making long COVID a priority in their organizations, making it easier for people to access long COVID care, and to support the people who are giving long COVID care. Numerous strategies were offered by stakeholders for supporting healthcare providers who are providing long COVID care. These include better characterization of the disease, increased treatment options, increased prevention efforts, advocacy, communication strategies, support for providers, collaboration with stakeholders, policy development, and learning from the success of advancement of care for other chronic conditions. Conclusion: Long COVID is a novel condition that requires change leadership support especially in the areas of diagnosis, access to care, communication, treatment, and provider knowledge and relations. It will take a multidisciplinary approach from a variety of stakeholders to create and implement a plan to support healthcare professionals who provide long COVID care. If these changes can be implemented and maintained, those who are suffering with long COVID symptoms can get to diagnosis and treatment more quickly and receive better quality care and treatment. This will have a positive impact on long COVID patients, their family members, employers, schools, medical professionals, health systems, governments, and the economy.
On Becoming a Chief Health Strategist
(2025-01) Brandenburg, Terry L.; Yeager, Valerie; Stone, Cynthia; Nelson, David
The vision for Public Health 3.0 includes a call to embrace the concept of health departments becoming chief health strategists. This term refers to public health organizations that possess the capacity and competency to take a leadership role in improving the health of communities. Although the practices of a chief health strategist have been defined, research is silent on “how” health departments can become proficient chief health strategists. The purpose of this study is to determine how local health departments can assimilate the role of chief health strategists within their communities. A qualitative multiple case study was designed to research this question. Eighteen local health directors from Wisconsin were selected and functioned as key informants. Semi-structured interviews were conducted, and participants completed a chief health strategist competency self-assessment survey and provided organizational documents. The key informant interview guide created for this study was developed using the five domains of the Consolidated Framework for Implementation Research (CFIR). Key findings of the study found four major themes that impact an organization’s ability to provide population health services and function as a proficient chief health strategist. The identification of facilitators and barriers to change and recommendations for change from the key informants served as the basis for the development of a plan for change. The plan for change was guided by John Kotter’s eight-step process of creating change model.
A Qualitative Study to Improve Performance of Medi-Cal's Grievance & Appeals System Through a New Conceptual Framework
(2025-01) Banks, La Rae Robin; Archer, Sarah E.; Coburn, Kenneth D.; Moore, Robert
In 2022, Medicaid expenses represented 18% of national health care spending costs totaling $805.7 billion, while health inequities cost approximately $146.8 billion. The Centers for Medicare & Medicaid Services (CMS) requires all Managed Care Organizations (MCOs) to administer a Grievance & Appeal (G&A) system if they provide medical coverage to any of the 88 million Medicaid beneficiaries living in the United States, giving Medicaid beneficiaries the legal right to report any problem using their Medicaid plan to their MCO who has a responsibility to investigate. This includes health inequities and disparities such as wrongfully denied hospitalizations, botched surgeries, discriminatory treatment, doctor refusing to treat Medi-Cal patients, and/or complaints against the MCO itself. Formally called Medi-Cal, California administers the largest state Medicaid program in the nation. In 2022, it incurred $109 billion in health care costs for its 15 million Medi-Cal enrollees, yet 70% of all MCOs were operating non-compliant with Federal and/or State G&A regulations according to evidence-based research. Member-reported problems go unsolved due to multiple deficiencies resulting untimely, ineffective, and incorrect investigations, if conducted at all. The number of G&A cases have increased by an astounding 480% since California enforced CMS’ Final Rule on July 1, 2017. This study explores the new Medi-Cal G&A Best Practice (M-GABp) Framework, a systems-thinking approach to improve the performance of Medi-Cal’s G&A system to foster a more equitable and accountable healthcare system. It establishes guiding principles for conducting high-quality investigations and resolving systemic issues equitably, while offering transparency to community stakeholders regarding G&A performance metrics and equitable solutions to inequitable problems. Drawing insights from 21 G&A Experts - including directors, physicians, investigators - who participated in three focus groups from 10 local MCOs, this deductive qualitative study examines their professional insights about the utility of the M-GABp Framework. Research findings showed G&A Experts agreed with M-GABp’s best practices and 85% agreed with transparency via MCPs’ website. It also revealed deficiencies responsible for today’s poor G&A performance. This paper provides a roadmap for implementation, leveraging Kotter’s 8-Step change management system to guide MCOs in adopting this transformative framework with continuous improvement post-implementation.
A Bridge to Dying Well: Understanding the Role of End-of-Life Doulas in Vermont with Implications for Policy Changes
(2024-12) Mize, Lucy Shackleford; Archer, Sarah E.; Walter McCabe, Heather; Mallon, Annetta
End-of-Life Doulas (EOLD) are an emerging profession attending to dying clients and their families. There are currently no national regulations, standards, or training mandates for EOLDs or policy solutions. Vermont has good EOLD training programs, a history of policy discussion on dying and an EOLD community organizing throughout the state, making it an excellent study site. There is a strong reluctance within the Vermont EOLD community to allow regulations for fear of creating barriers to entry to practice. EOLDs wish to contribute to any legislative processes impacting their work. Vermont EOLDs are implementing new models that rely on collective services to optimize care, provide an adequate income stream and respond to socio-geographic factors. Collectives allow for a community of practice to flourish, where EOLDs with experience can collaborate. Because current training models do not emphasize practical learning or address grief and loss in the community, collaboration is essential. Foundational training should be standardized so Vermont EOLDs have common skills and knowledge, while still bringing their unique backgrounds and talents to each client. There is little consensus on the need for regulation, and whether payment validates their skills or negates the sacred nature of their work. EOLD’s roles are much larger than the literature would suggest, with significant effort being devoted to death literacy as well as promoting agency in the dying. This research illustrates that these providers are making a significant contribution to the well- being of Vermonters and proposes nine policy recommendations to public health leaders and legislators. EOLDs need very little regulation to continue delivering essential services amidst a state-wide health care system that is seriously strained by its aging population and poverty, and they need a living wage. Or as one Vermont EOLD said “we look at this rich end of lifetime as a time of coming to terms, of healing places that still need to heal, of celebrating and affirming and rejoicing and validating the things that were rich and precious. And mourning the things that will be lost, and feeling all of the depths of that, just the whole package. It’s an amazing opportunity.”
Enabling Policy to Advance Black Maternal Health Equity Through the Use of Doulas in Indiana
(2024-08) Brown, Jenell Nicole; Archer, Sarah E.; Jackson, Emily; Walter-McCabe, Heather
Disproportionately high maternal mortality rates (MMR) among Black women continue to be a significant public health equity concern in the United States, particularly in the state of Indiana, where Black women experienced the highest MMR at 156.3 deaths per 100,000 live births in 2021. In comparison, White women experienced 90.7 deaths per 100,000 live births in the same year (Indiana Department of Health, 2024). Equity recognizes that high-risk populations have different needs and disadvantages and aims to address disparities by providing targeted opportunities, resources, and support to account for these differences. Health equity is achieved when everyone can attain their full potential for health and well-being (World Health Organization, n.d.). Equality refers to equal access for everyone, which in turn perpetuates inequities. While not the sole solution to Indiana’s Black maternal health equity crisis, Doulas are an evidence-based solution to reducing racial disparities in maternal health outcomes. Building on the current body of literature, this dissertation explores how Indiana can enable policy to expand access to Doula care and integrate Doula services into maternal healthcare systems. Through the employment of qualitative, semi-structured interviews with Doulas and other key stakeholders, findings identified that current barriers in Indiana include a lack of a supportive environment to legitimize the profession, lack of Medicaid reimbursement and inadequate private insurance coverage, processes that “medicalize” Doula care, and the need for collaborative efforts with Doulas when crafting Doula-related policies. By leveraging a policy and stakeholder analysis, an implementation plan was developed to provide recommendations on how Indiana policy can advance Black maternal health equity through the use of Doulas. This research's importance lies in its potential to inform policy and practice in Indiana and provide foundational information for other states that have yet to begin incorporating Doula care into policy to advance maternal health equity.
Physician Compensation Models and Quality of Healthcare Services in the United Arab Emirates
(2023) Elrefaey, Mahmoud; Tierney, William Michael; Babich, Suzanne M.; Czabanowska, Katarzyna
Physicians working in different healthcare systems receive financial compensation by means of several structures (e.g., the salaried model, the fee-for-service model, and the revenue-share model) depending on how and where they practice. Most research on the relationships, if any, between physicians' compensation models and the outcomes of healthcare services has been conducted in North America and Europe, but no equivalent research has been conducted in the United Arab Emirates (UAE). The purpose of my exploratory qualitative research study was to address two open-ended research questions: 1) what are the perceptions of hospital stakeholders about the idiographic effects of different physician payment models on quality of healthcare services in the hospital? 2) What changes might be implemented to physician payment models to improve healthcare services in the hospital? I audio-recorded semi-structured interviews with a purposive sample of N = 17 stakeholders at one private sector hospital in UAE. The heterogenous or maximum variation sample included five hospital leaders, two financial or insurance managers, five physicians, two nurses, and three patients. I conducted a qualitative analysis and identified ten primary semantic themes by deductive reasoning to address the first research question. I based four semantic themes on a template extracted from the literature, specifically: 1) Physician Payment Models Implemented at the Hospital; 2) Environmental Context for Payment Models; 3) Stakeholders Affected by Payment Models; 4) Misuse of Payment models. I underpinned six semantic themes by the dimensions of healthcare quality proposed by the Institute of Medicine, specifically: 5) Payment Models and Safe Care; 6) Payment Models and Effectiveness of Care; 7) Payment Models and Patient-Centered Care; 8) Payment Models and Timely Care; 9) Payment Models and Efficiency of Care; 10) and Payment Models and Equity of Care. Subsequently, I synthesized the semantic themes and identified two latent themes by inductive reasoning, specifically: 1) Relationships between Physicians' Compensation Models and Healthcare Services; and 2) Proposed Changes to Physician Compensation Models. I propose innovative changes underpinned by Kotter's Management Change Theory and Roger's Theory of Diffusion of Innovations. I recommend future confirmatory research using a quantitative correlational design to validate these themes.
Examining Policy Solutions to Address Barriers Impeding the Adoption of Universal Adverse Childhood Experiences (ACE) Screening in Pediatric Primary Care Settings
(2024-05) Ball, Tristyn Denyse; Archer, Sarah E.; Coburn, Kenneth; Jones-Kelley, Helen
Over 93% of adults in Western Ohio have experienced at least one adverse childhood experience (ACE). This figure is significantly higher than the national average of 61% of adults who have experienced at least one ACE. Exposure to adversity in childhood increases levels of toxic stress, impacts brain development, and creates a predisposition for a variety of psychological and physiological ailments known as ACEassociated health conditions. While many pediatric healthcare professionals understand the implications associated with ACE exposure, the integration of ACE screening in pediatric healthcare facilities in the region is limited. The study aimed to determine the barriers to implementing ACE screening in pediatric primary care settings in Western Ohio and identify policy levers to increase the integration of ACE screening and care among pediatric healthcare professionals. The study used thematic analysis to identify themes in the results, as there is limited existing research in this area. Key informant interviews were conducted with local pediatric healthcare professionals to determine their views regarding the potential barriers and facilitators associated with implementing universal ACE screening in their organizations. The results concluded that barriers around workforce shortages, perceived diminished patient relationships, time, ethics, reimbursement, and overall discomfort lead to low screening integration in local pediatric healthcare organizations. Ohio’s current pediatric healthcare infrastructure can be leveraged to ease the implementation of the statewide initiative. ACE screening can be integrated into Ohio’s Early and Periodic Screening, Diagnosis, and Treatment program, which provides guidelines for developmental screening. Further, advocacy for the integration of ACE screening in the American Academy of Pediatrics Bright Future Guidelines will increase the utilization of the tool. The current state General Assembly has introduced legislation focusing on ACEs, and with new streams of state tax revenue, the policy window to advance this initiative is open.

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